Proposed Changes to the DSM5 Which Effect Bipolar Children

The Addition of Temper Dysregulation Disorder with Dysphoria

Recently, the American Psychiatric Association (APA), as part of its plan to revise the current Diagnostic and Statistical Manual (DSM), set forth it’s ideas on how to refine the diagnostic process for childhood bipolar disorder.

It’s solution is to create a new diagnosis, Temper Dysregulation Disorder with Dysphoria ( TDDD) . The intention of this diagnosis is to separate children who have mood dysregulation, temper outbursts and chronic irritability from children who are bipolar. The belief is that this group of children does not clearly exhibit mania, the hallmark feature of bipolar disorder, and they have been inappropriately categorized as bipolar. The creation of this category is an effort to prevent kids from getting misdiagnosed and mistreated ( DSM 5 Childhood and Adolescent Disorders Work Group, 2010).

Based on reviewed research, the workgroup believes that children that meet the criteria, in absence of mania, are more likely to evolve into anxiety based or unipolar depressive type illness in adulthood. This helps explain the recent evidence which has suggested that some children grow out of bipolar disorder (Cicero DC, 2009). The idea of a separate diagnosis is somewhat supported by this research. These children in the study may be those with TDDD. They grew out of this disorder because they never had it in the first place!

The Good

The workgroup recognized that child bipolar exists and looks distinctively different from adult bipolar. They made an effort to understand how the illness is different. If the committee is right about their understanding of childhood mania and the illness itself, the new diagnosis may help children who are improperly diagnosed as bipolar receive more appropriate treatment.

The Bad

The category ignores the research the JBRF is doing on the illness. It may create unanticipated consequences for a group of children who don’t meet their diagnostic criteria for bipolar ( because it may be wrong). If the committee is wrong about their understanding of the illness and definition of mania, these children may receive improper treatment, the wrong medicine, and the wrong diagnosis when they actually have bipolar disorder.

A Little Background on the Diagnosis

Many people seem to misunderstand and think TDDD is a replacement for Child Bipolar Disorder. Several people have said to me “Did you hear they were getting rid of Child Bipolar Disorder in the new DSM?”

Actually, there isn’t a separate category for Childhood Bipolar. Current criteria are based on studies of adults. As it is written, the DSM does little to help us adequately describe bipolar disorder in children. To further complicate the problem, we still don’t understand the illness; we are learning new things every day.

Children have mood cycles that don't meet the criteria for duration in the DSM definition. Symptoms of mania and depression also look very different in children than they do in adults. Symptoms of Attention Deficit Disorder (ADD), Oppositional Defiant Disorder (ODD), and anxiety disorders also overlap with Bipolar Disorder in a way that makes it difficult to tease out . This group focused primarily on how to correctly define childhood mania.

The Problems that Need to be Fixed

The current diagnostic criteria leave too much room for clinicians and other professionals who are untrained to make the wrong diagnosis. It’s imprecise and ignores much of what we do know from research.

Children who are misdiagnosed as bipolar when they are not, or misdiagnosed with other disorders when they have bipolar disorder, are given the wrong treatment. This can have disastrous consequences in either case.

It's a good idea on the surface, to explore research and make changes to help these kids! What’s all the fuss about?

Concerns with the Proposed Changes

1.Things Could get Worse.

One concern expressed by JBRF is that kids diagnosed with TDD according the criteria the committee has set may be bipolar. This misdiagnosis would perhaps lead to medication with SSRIS, the treatment of choice for unipolar depression and anxiety. This could actually make things worse (JBRF, 2010)

2.Basic Flaws in DSM’s Conceptualization of Mental Illness

Another concern expressed by the JBRF is that much of their research on this illness is ignored. It’s important to understand that this organization believes our current view of mental illness is inherently flawed. The categorical approach of the DSM (unique and separate symptoms which assign people to different diagnosis) is wrong. They believe in a dimensional approach (clusters of symptoms which come together to create different categories with overlap). They see Bipolar Disorder as involving much more than mania and depression, but a cluster of symptoms that includes sleep disorders, psychosis, carbohydrate cravings, and obsessions.

JBRF has done extensive research on phenotypes, categories of children who are bipolar who have clusters of these symptoms. I believe the work they are doing is on track. Bipolar children have a unique cluster of symptoms that is in no way captured by the new revisions (JBRF, 2010).

3.Appropriate Treatment for Kids who have Bipolar.

The main issue here, frequently lost in this debate, is whether these changes will improve treatment to kids who have bipolar disorder. This group of children and families for the last two decades has been harmed tremendously by the very system that is set up to help them. The families I work with fight constantly: for a diagnosis, for the right medicine, for appropriate education, and for acceptance in their community and family. Children can literally die in the process. Unfortunately, the truth is that we don’t know what impact these changes in the DSM will have on our children.

4. Politics?

What is most confusing is that the two major organizations that support work and research with child bipolar (CABF) and (JBRF) seem clearly divided on this diagnostic category. THE CABF is much more supportive in their perspective, defending the research behind the proposed changes in their statements (CABF, 2010).

This is all so hard to understand!! We really don’t know how this category will effect kids who have bipolar disorder, or other disorders. Parts of the committee arguments make sense. However, the work the JBRF is doing is significant, and their perspective isn’t taken into consideration. The fact remains that there is much we don’t understand about this illness. Children deserve our full commitment to getting it right. I will continue to explore this topic and to update you as changes develop.

The new DSM categories are currently open for discussion. It will take three years for these new ideas to be incorporated into the DSM, if they are. If you are interested in giving your input click here and submit it!.